To evaluate QOL changes during pregnancy in developed country, we analyzed 159 pregnant Japanese women (67 nulliparous and 92 multiparous) who had no complications during pregnancy. Subjects were asked to complete the Medical Outcomes Study Short Form (SF-36) every 4 weeks up to 24 weeks of gestation, and every 2 weeks from 24 weeks of gestation until delivery. Subscales that reflect "Physical functioning (p?0.001)", "Role-physical (p?0.001)" and "Bodily pain (p?0.001)" showed significant declines throughout the entire pregnancy. On the other hand, subscales that reflect "Vitality," "General health" and "Mental health" did not change substantially with gestational age. Furthermore, subscales that reflect "Physical functioning," "Role physical," "General health" showed no significant differences between nulliparous and multiparous women. Although subscales that reflect "Bodily pain," "Vitality," "Social functioning," "Role emotional" and "Mental health" showed significant differences between nulliparous and multiparous women, these subscales showed significant interactions. Our results suggest that pregnant women need support, regardless of the number of deliveries. Appropriate supports to pregnant women will be available to improve the birth rate in developed countries

Abe Yasuyo

Aoyagi Kiyoshi

Hama Kouko

Honda Sumihisa

Imamura Sadaomi

Miyamura Tsunetake

Morisaki Masayuki

Obama Masahiko

Takamura Noboru

Yagura Chiaki

Nagasaki University's Academic Output SITE: NAOSITE

AbbreviationsQOL: quality of life, SF-36: Medical Outcomes Study Short Form,BMI: body mass indexIntroductionDeclining birth rate is one of the important and common issues indeveloped countries. In Japan, marriage is delayed and postponeduntil later in life, an increasing number of women choose to remainsingle, and there are fewer children even among married couples.The total fertility rate decreased to 1.26 in 2005 and is one of thelowest fertility rates in the world.1 Besides the appropriate imple-mentations of social, economical and political strategies, improve-ment of women's health, according to the profiles of each stageduring pregnancy should be carefully taken into account, in orderto recover the fertility rate in developed countries including Japan.Furthermore, evaluation of the health effects of multiple pregnanciesfor women is also very important, to provide support for womenwho wish to have multiple deliveries.On the other hand, pregnancy causes profound physical, mental,and social changes for a woman. For example, physical problems,such as breast tenderness, nausea, general fatigue and sleepinessoccur even during normal pregnancy.2,3 These problems, in combina-tion with emotional reactions to pregnancy, limit a pregnant woman'sActa Med. Nagasaki 52: 95－99Address correspondence: Noboru Takamura, M.D., Ph.D. Department of Public Health, Nagasaki University Graduate School of Biomedical Sciences,1-12-4 Sakamoto, Nagasaki 852-8523 JAPANTEL: +81-(0)95-819-7066, FAX: +81-(0)95-819-7069, E-mail: takamura@nagasaki-u.ac.jpReceived November 7, 2007; Accepted February 25, 2008Evaluation of Quality of Life in Japanese Normal Pregnant WomenKouko HAMA,1,2,3 Noboru TAKAMURA,1 Sumihisa HONDA,4 Yasuyo ABE,1 Chiaki YAGURA,1 Tsunetake MIYAMURA,5Masahiko OBAMA,6 Masayuki MORISAKI,7 Sadaomi IMAMURA,8 Kiyoshi AOYAGI11 Department of Public Health, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan2 Siebold University of Nagasaki, Nagasaki, Japan3 Mie University Graduate School of Medicine, Mie, Japan4 Research Center for Tropical Infectious Diseases, Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan5 Miyamura Hospital, Nagasaki, Japan6 Obama Ladies Clinic, Nagasaki, Japan7 Takara Maternity Clinic, Nagasaki, Japan8 Imamura Women's Hospital, Nagasaki, JapanTo evaluate QOL changes during pregnancy in developed country, we analyzed 159 pregnant Japanese women (67 nulliparous and 92multiparous) who had no complications during pregnancy. Subjects were asked to complete the Medical Outcomes Study Short Form (SF-36)every 4 weeks up to 24 weeks of gestation, and every 2 weeks from 24 weeks of gestation until delivery. Subscales that reflect "Physical func-tioning (p<0.001)", "Role-physical (p<0.001)" and "Bodily pain (p<0.001)" showed significant declines throughout the entire pregnancy. On theother hand, subscales that reflect "Vitality," "General health" and "Mental health" did not change substantially with gestational age. Furthermore,subscales that reflect "Physical functioning," "Role physical," "General health" showed no significant differences between nulliparous andmultiparous women. Although subscales that reflect "Bodily pain," "Vitality," "Social functioning," "Role emotional" and "Mental health" showedsignificant differences between nulliparous and multiparous women, these subscales showed significant interactions. Our results suggest thatpregnant women need support, regardless of the number of deliveries. Appropriate supports to pregnant women will be available to improvethe birth rate in developed countries.ACTA MEDICA NAGASAKIENSIA 52: 95－99, 2008Keywords: Fertility rate; Medical Outcomes Study Short Form (SF-36); Number of deliveries; Quality of Life (QOL)Kouko Hama et al.: QOL in Pregnant Womenactivities and lower quality of life (QOL). Using "Medical OutcomesStudy Short Form (SF-36)," which is a standard measure of QOLfor "serial assessments of health-related functional status,"4-6 severalstudies showed declining QOL scores in the "Physical functioning"subscale during the early stages, and in the "Role-physical" and"Bodily pain" subscales during the middle and late stages of nor-mal pregnancy, respectively.3,7 In addition, physical and emotionalchanges during pregnancy can reportedly alter the ability to under-take the normal activities of daily life.8-11 These findings suggestthat, given the changes in QOL, careful support of pregnant womenis essential, particularly from the family.Furthermore, nulliparous and multiparous women experience dif-ferent health problems during pregnancy. It has been reported thatmultiparous women, compared with nulliparous women, have morehealth problems, such as back pain and obesity.12-14 However, the ef-fect of the number of deliveries on women's QOL during pregnancyhas received less attention.15 In order to recover the fertility rate indeveloped countries, evaluation of QOL changes of multiparouswomen and nulliparous women should be considered to improvetheir health environment.With these considerations, we evaluated chronological changes ofQOL in normal pregnant Japanese women throughout pregnancy andthe effects of the number of deliveries in this study.MethodsStudy ParticipantsBefore the study, ethical approval was obtained from the specialcommittee of Siebold University of Nagasaki (project registration#39).The study was conducted from August 2005 to September 2006.Subjects included 190 Japanese women (in the early gestational pe-riod) who initiated maternity care at one of 4 hospitals and clinics inNagasaki city (Japan) and who were invited to participate in thestudy. At initial examination, details of the study were explained toeach participant. Informed consent was obtained from all partici-pants before enrollment in the study. A total of 16 participants whodeveloped complications (extracorporeal fertilization, abortion,antepartum fetal death, pregnancy-induced hypertension, prematuredelivery, and other medical complications) and 12 participants whotransferred to other hospitals and clinics or returned to their home-town for delivery were excluded from the analysis. Three partici-pants who did not report the number of deliveries were also excludedfrom analysis. A total of 159 pregnant women were thus included forfinal analysis.Questionnaire AdministrationEach study participant was asked to complete a self-administeredquestionnaire. In addition to number of deliveries, sociodemographicvariables were also elicited including age, body mass index (BMI),occupational status, family composition, and whether the currentpregnancy was planned.Every 4 weeks up to 24 weeks of gestation, and then every 2weeks from 24 weeks of gestation until delivery, study participantswere asked to complete the Medical Outcomes Study Short-Form 36(Japanese edition of SF-36) version 2 Acute (iHope International,Japan). The questionnaire consists of 36-items generating 8 dimen-sions of functioning: "Physical functioning" (10 items); "Role-physical" (4 items); "Bodily pain" (2 items), "General health" (5items), "Vitality" (4 items), "Social functioning" (2 items); "Role-emotional" (3 items) and "Mental health" (5 items) (Table 1, (16)).These 8 subscales are separately scored from 0 (lowest) to 100(highest).Statistical AnalysisTo evaluate the difference between nulliparous and multiparouswomen, we used a general linear model in each subscale. Values ofp<0.05 were considered statistically significant. Statistical analyseswere performed using SPSS version 11.0 software (SPSS Japan,Tokyo, Japan), and GLM in the SAS system (SAS Institute Inc.Cary, USA).96Dimension Item number DefinitionPhysical functioning 10 Extent to which health interferes with a variety of activities in lifeRole-physical 4 Problems with work or other daily activities as a result of physical health in the last weekBodily pain 2 Extent of bodily pain in the last weekGeneral health 5 Personal evaluation of general healthVitality 4 Perception of degree of fatigue or energy in the last weekSocial functioning 2 Extent to which health interferes with normal social activities in the last weekRole-emotional 3 Problems with work or other activities as a result of emotional problems in the last weekMental health 5 General mood or affect, psychological well-being in the last weekTable 1. Dimensions in the Medical Outcomes Study Short Form 36 QuestionnaireKouko Hama et al.: QOL in Pregnant WomenResultsSubject attributesTable 2 shows subject attributes. Age was ranged from 20 to 39years old at beginning of the study, and its mean was 29.5 ± 4.2.BMI was ranged from 16.4 to 32.4 at beginning of the study, and itsmean was 20.3 ± 2.4. While 67 women were nulliparous (42.1%), 92women were multiparous (once: 69 (43.4%); twice 22 (13.8%) andthree times 1 (0.6%)). In the present study, 90 women (56.6%) hadplanned pregnancy.As to other attributes, 122 women (76.7%) lived in nuclear fam-ily households. In addition, 87 women (54.7%) worked while preg-nant.Subscales of QOL and gestational ageSubscales that reflect "Physical functioning (p<0.001)," "Role-physical (p<0.001)" and "Bodily pain (p<0.001)" showed significantdeclines throughout the entire pregnancy (Figure 1a, 1b and 1c). Onthe other hand, subscales that reflect "Social functioning" and "Role-emotional" declined in the third trimester. Subscale that reflects"Vitality" did not change substantially with gestational age, exceptfor 12-15 weeks. Also, subscales that reflect "General health" and"Mental health" did not change substantially with gestational age.Figure 1a-h show the comparison of QOL scores between nulliparousand multiparous women for each subscale. Subscales that reflect"Physical functioning", "Role physical", "General health" showed nosignificant differences between nulliparous and multiparous women.On the other hand, subscales that reflect "Bodily pain," Vitality,""Social functioning,", "Role emotional," and "Mental health" showedsignificant differences between nulliparous and multiparous women(p=0.006, 0.007, 0.002, 0.041 and <0.001, respectively). However,these subscales showed significant interactions between nulliparousand multiparous women (p<0.001, 0.002, 0.006, 0.049 and 0.004, re-spectively). For example, in subscales that reflect "Bodily pain" and"Vitality," adjusted SF-36 scores were higher in multiparous than innulliparous women from 12-15 weeks to 16-19 weeks, whereas thosewere lower in multiparous than in nulliparous women from 36-37weeks to 38-39 weeks.DiscussionIn the current study, we showed that subscales that reflect "Physicalfunctioning," "Role-physical," "Bodily pain," "Social functioning"and "Role-emotional", showed significant decline throughout theentire or partial gestation, whereas subscales that reflect "Vitality,""General health" and "Mental health" did not change during thegestation. Pregnancy has been considered a time of great emotionaland physical upheaval, but our current results suggest that whilepregnancy produces a predictable effect on physical function, it hasmuch limited impact on emotional health status, and that SF-36 isa useful tool especially for evaluating functional status in pregnantas well as non-pregnant women.Furthermore, our results showed that subscales that reflect "Physicalfunctioning," "Role physical," "General health" showed no significantdifferences between nulliparous and multiparous women. Althoughsubscales that reflect "Bodily pain," Vitality," "Social functioning,""Role emotional," and "Mental health" showed significant differ-ences between nulliparous and multiparous women, these subscalesshowed significant interactions between nulliparous and multiparouswomen. Interestingly, in subscales that reflect "Bodily pain" and"Vitality," adjusted SF-36 scores were higher in multiparous thanin nulliparous women from 12-15 weeks to 16-19 weeks, whereasthose were lower in multiparous than in nulliparous women from36-37 weeks to 38-39 weeks. Also, subscale that reflects "Socialfunctioning" tended to be higher in multiparous than in nulliparouswomen from 12-15 weeks to 28-29 weeks, whereas those werelower in multiparous than in nulliparous women in 38-39 weeks.These results suggest in both multiparous and nulliparous women,changes of QOL are observed in a certain period. Although we tendto underestimate the QOL change for women who experience child-birth, our current findings showed that QOL of multiparous, as wellas nulliparous women tends to decline during pregnancy. Regardlessof the number of deliveries, we should effectively support pregnantwomen, according to changes that occur in the QOL.97Background Number (%)Age Twenties 78 (49.1)Thirties 81 (50.9)BMI (Body Mass Index) prior to pregnancy閏18.4 26 (16.4)18.5-24.9 118 (74.2)噂25 4 (2.5)Not evaluated 11 (6.9)Employed outside home Yes 87 (54.7)No 72 (45.3)Composition of family Nuclear family 122 (76.7)Stepfamily 31 (19.5)Unknown 6 (3.8)Number of deliveries Nulliparous 67 (42.1)Multiparous (once) 69 (43.4)Multiparous (twice) 22 (13.8)Multiparous (three times) 1 (0.6)Planning of current pregnancyYes 90 (56.6)No 69 (43.4)Table 2. Background of 159 pregnant women who completed the SF-36Kouko Hama et al.: QOL in Pregnant Women98acbde fg hFigure 1. Comparison of QOL scores between nulliparous (■ ) and multiparous (□) women for each subscale during pregnancy. a. Physical functioning,b. Role-physical, c. Bodily pain, d. Vitality, e. Social functioning, f. Role-emotional, g. General health and h. Mental health.Kouko Hama et al.: QOL in Pregnant WomenIn Japan, decrease of fertility rate is an important social issue. In2003, total fertility rate of Japan was 1.29. According to the latestdemographic projection by the National Institute of Population andSocial Security Research, Japan's population, currently 127 millionwill decline to 100 million by 2050, and will further decline to 64million by the end of the century.17,18 Also in other developed coun-tries, a drop in the fertility level has been observed. Birth rates inEU countries have on average decreased by 0.1%, falling to the low-est level ever in some countries where rates have been high in thepast.18 On the other hands, a minor baby boom has shown in France,according to the report from France's National Institute of Statisticsand Economic Studies. The birth rate in France has increased from1.88 in 2000 to 1.89 in 2002. France's birth rate is now same as therate in the Republic of Ireland, which for several years has had thehighest birth rate in the European Union. The increase of birth ratein France is mainly due to the effective Governmental policies, in-cluding financial supports to families which have more than twochildren, improving of nursery serves and careful consideration ofworking system to mothers, which suggest not only the individualcare for pregnant women, but also effective Governmental policyis definitely needed to improve birth rate.In 2004, the Japanese Government outlined "Child-Care SupportPlan", which presents specific measures and objectives for 2005 to2009, with a focus on four priority issues cited in the general poli-tics of measures for the society with fewer children. This plan hasfour priority issues as follows:1. Promoting the independence of young persons and the nurturingof healthy, active children.2. Reconciling work and family life and revising work styles.3. Promote understanding of the values of human life and the fam-ily's care.4. Promoting further collaboration and mutual support in childcare.In combination of individual care to each pregnant women andimplementation of above mentioned governmental policies, appro-priate strategies to improve birth rate should be carefully consid-ered in developed countries, including Japan.Our study has several limitations. The number of participants wasrelatively small. Other socio-economical factors, which may affectthe changes of QOL, were not considered. Further studies will beessentially needed.In conclusion, we clarified the changes of QOL during normalpregnancy, and suggest that pregnant women need support, regard-less of the number of deliveries. Appropriate supports to pregnantwomen will be available to improve the birth rate in developedcountries.References1. Vital statistics of Japan 2004 (Statistics and Information Department, Ministry ofHealth, Labour and Welfare of Japanese Government & Health and WelfareStatics Association. Tokyo), 20042. Hockenberry M. Nursing care during pregnancy. In Maternal child nursing care(Wong D, Perry SE eds.; Mosby, St. Louis) 43-60, 20053. Hueston WJ, Kasik-Miller S. Changes in functional health status during normalpregnancy. J Fam Pract 47: 209-12, 19984. Stansfeld SA, Roberts R, Foot SP. Assessing the validity of the SF-36 GeneralHealth Survey. Qual Life Res 6: 217-24, 19975. Hemingway H, Stafford M, Stansfeld S, Shipley M, Marmot M. Is the SF-36 avalid measure of change in population health? Results from the Whitehall II Study.BMJ 315: 1273-79, 19976. Garratt A, Schmidt L, Mackintosh A, Fitzpatrick R. Quality of life measurement:bibliographic study of patient assessed health outcome measures. BMJ 324: 1417-21, 20027. Otchet F, Carey MS, Adam L. General health and psychological symptom statusin pregnancy and the puerperium: what is normal? Obstet Gynecol 94: 935-41,19998. Gjerdingen DK, Froberg DG, Fontaine P. The effects of social support on women'shealth during pregnancy, labor and delivery, and the postpartum period. Fam Med23: 370-75, 19919. Mckee MD, Cunningham M, Jankowski KR et al. Health-related functional statusin pregnancy: relationship to depression and social support in a multi-ethnic popu-lation. Obstet Gynecol 97:988-93, 2001.10. Attard CL, Kohli MA, Coleman S et al. The burden of illness of severe nausea andvomiting of pregnancy in the United States. Am J Obstet Gynecol 186(Suppl 5):S220-27, 200211. Jomeen J, Martin CR. The factor structure of the SF-36 in early pregnancy. JPsychosom Res 59: 131-38, 200512. Mogren IM, Pohjanen AI. Low back pain and pelvic pain during pregnancy:prevalence and risk factors. Spine 30:983-91, 200513. Rossner S. Pregnancy, weight cycling and weight gain in obesity. Int J Obes RelatMetab Disord 16:145-47, 199214. Bastian LA, West NA, Corcoran C, Munger RG. Number of children and the riskof obesity in older women. Prev Med 40: 99-104, 200515. Kita A. Quality of social network for pregnant women in Japan with focus on par-ity and family structure. Kobe J Med Sci 46:125-36, 200016. Ware JE Jr, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey Manual andInterpretation Guide. Boston (MA): The Health Institute, New England MedicalCenter, 199317. Population Statistics of Japan 2006. National Institute of Population and SocialSecurity Research, Japan's population. http://www.ipss.go.jp/p-info/e/PSJ2006.pdf18. Watts J. Japan opens dating agency to improve birth rate. Lancet 360: 1755, 200219. Dorozynski A. France's birth rate matches high Irish levels. Lancet 324: 385, 200299

Evaluation of Quality of Life in Japanese Normal Pregnant Women

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Evaluation of Quality of Life in Japanese Normal Pregnant Women

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